Images in Clinical Neurology
Transient Cluster Breathing Associated With Anoxic Encephalopathy
The Neurohospitalist 2014, Vol 4(1) 44-45 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1941874413493186 nhos.sagepub.com
James P. Battista, MD1, and Matthew S. Robbins, MD1 Keywords anoxic brain injury, cardiac arrest, cluster breathing
Figure 1. Respiratory monitoring showing rapid paroxysms of breathing without a crescendo-decrescendo pattern and interspersed with periods of apnea, characteristic of cluster breathing.
A 75-year-old man sustained an out-of-hospital asystolic arrest, with return of spontaneous circulation after 5 minutes of chest compressions, norepinephrine, and sodium bicarbonate. Several hours later, he developed generalized myoclonus, resolving after the administration of midazolam, propofol, and fosphenytoin. After holding these medications on hospital day 2, the myoclonus did not return. Computed tomography revealed a chronic right parietal infarct, and a 2-hour electroencephalogram was invariant with burst suppression. Examination on days 1, 2, and 3 revealed coma with only a cough reflex present, and he was breathing over the set rate of the ventilator. On day 4, he lost his cough reflex and developed short bursts of rapid respirations consistent with cluster breathing (Figure 1), resolving the next day and subsequently requiring the ventilator to initiate respirations. Ultimately, palliative care was pursued, and the patient was terminally extubated and died on hospital day 6. Cluster breathing is a classic but rarely reported phenomenon associated with lesions of the lower pons or upper medulla.1
In our patient, the contemporaneous loss of cough reflex with the transient presence of cluster breathing may have reflected a rostrocaudal progression of cerebral edema after anoxic injury. Authors’ Note The article has not been submitted for publication elsewhere, and all authors have contributed substantively to (1) the conception, design, or analysis and interpretation of the data, (2) the drafting of the manuscript or critical revision for important intellectual content, and
1
Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, USA Corresponding Author: James P. Battista, Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, 3351 Steuben Ave, 3rd Floor, Bronx, NY 10467, USA. Email: [email protected]
Downloaded from nho.sagepub.com at UNIV ARIZONA LIBRARY on August 10, 2015
Battista and Robbins
45
(3) the final approval of the version to be published. Informed consent was obtained from the patient/surrogate.
Funding
Declaration of Conflicting Interests
Reference
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1. Plum F, Posner JB. The Diagnosis of Stupor and Coma. 3rd ed. New York, NY: Oxford University Press; 1982.
The authors received no financial support for the research, authorship, and/or publication of this article.
Downloaded from nho.sagepub.com at UNIV ARIZONA LIBRARY on August 10, 2015
Transient Cluster Breathing Associated With Anoxic Encephalopathy
The Neurohospitalist 2014, Vol 4(1) 44-45 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1941874413493186 nhos.sagepub.com
James P. Battista, MD1, and Matthew S. Robbins, MD1 Keywords anoxic brain injury, cardiac arrest, cluster breathing
Figure 1. Respiratory monitoring showing rapid paroxysms of breathing without a crescendo-decrescendo pattern and interspersed with periods of apnea, characteristic of cluster breathing.
A 75-year-old man sustained an out-of-hospital asystolic arrest, with return of spontaneous circulation after 5 minutes of chest compressions, norepinephrine, and sodium bicarbonate. Several hours later, he developed generalized myoclonus, resolving after the administration of midazolam, propofol, and fosphenytoin. After holding these medications on hospital day 2, the myoclonus did not return. Computed tomography revealed a chronic right parietal infarct, and a 2-hour electroencephalogram was invariant with burst suppression. Examination on days 1, 2, and 3 revealed coma with only a cough reflex present, and he was breathing over the set rate of the ventilator. On day 4, he lost his cough reflex and developed short bursts of rapid respirations consistent with cluster breathing (Figure 1), resolving the next day and subsequently requiring the ventilator to initiate respirations. Ultimately, palliative care was pursued, and the patient was terminally extubated and died on hospital day 6. Cluster breathing is a classic but rarely reported phenomenon associated with lesions of the lower pons or upper medulla.1
In our patient, the contemporaneous loss of cough reflex with the transient presence of cluster breathing may have reflected a rostrocaudal progression of cerebral edema after anoxic injury. Authors’ Note The article has not been submitted for publication elsewhere, and all authors have contributed substantively to (1) the conception, design, or analysis and interpretation of the data, (2) the drafting of the manuscript or critical revision for important intellectual content, and
1
Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, USA Corresponding Author: James P. Battista, Department of Neurology, Montefiore Medical Center, The Albert Einstein College of Medicine, 3351 Steuben Ave, 3rd Floor, Bronx, NY 10467, USA. Email: [email protected]
Downloaded from nho.sagepub.com at UNIV ARIZONA LIBRARY on August 10, 2015
Battista and Robbins
45
(3) the final approval of the version to be published. Informed consent was obtained from the patient/surrogate.
Funding
Declaration of Conflicting Interests
Reference
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
1. Plum F, Posner JB. The Diagnosis of Stupor and Coma. 3rd ed. New York, NY: Oxford University Press; 1982.
The authors received no financial support for the research, authorship, and/or publication of this article.
Downloaded from nho.sagepub.com at UNIV ARIZONA LIBRARY on August 10, 2015
